What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior?
Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)

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Sunday, January 27, 2013

Should Pathologists Be Physicians??

What I am about to write I am sure will be considered by some as controversial and perhaps likely illogical but after a bit of consideration I felt I just had to write the question to my ethics blog. "Should pathologists be physicians?" and if not, shouldn't the profession be noted by their members bearing a different doctorate (a PhD) rather than an MD or DO as is currently the case? So, some may ask who are pathologists and what do they do and why does the name of the degree make a difference? I would say that pathologists are professional men and women whose interest is how human disease or injury is expressed in anatomic or functional ways and through research and examination provide a service to physicians and the physicians' patients in making a diagnosis of the living ill through a laboratory test or anatomical conclusion. They also provide a service, beyond that to the medical profession, families and to the civic community, law enforcement and public health by their work in coroners' offices and hospitals as they diagnose the mechanism which led to the individual's death.

But the basis for my writing this thread is my understanding, after years of an internal medicine career interacting with pathologists, that in the many active roles of being a pathologist, except for the occasional pathologist directly performing a procedure such as a needle biopsy on a live human, virtually all of their work related to the living patient is that of inspecting fragments of tissues either through the microscope or directly examining the patient's gross organs or tissues which were to be or were removed by a surgeon or other physicians. Some pathologists operate their laboratories or do scientific research in their field of interest. Clinical pathologists are primarily consultants for the patient's physicians, the latter being the professionals directly responsible for the patient's care and treatment. On some occasions pathologists may communicate directly with the patient or family to explain the findings. Though their professional input may be essential to diagnosis and treatment and their diagnostic decisions clearly an ethical and legal responsibility to the patient, nevertheless, the pathologists are not direct caregivers as are physicians.

So what does the description of the work of a pathologist have anything to do with their doctoral title or their primary care of a patient? My primary argument has to do with the training necessary to obtain the MD or DO degrees. I have been teaching medical students for over 25 years and though they start out with dissecting a cadaver for learning anatomy and they are provided extensive education in physiology, pharmacology and pathological changes in the human body, the primary orientation of their four years of medical education to obtain their MD or DO is how to interact directly with a live but sick human. My issue is whether those who become pathologists really need all those hours, days, weeks, months and years of intimate and intense attention and care to the daily changes in the history, physical, evaluation, diagnosis and treatment of a live patient. Wouldn't it be more appropriate for pathologists to begin their careers within a separate educational environment, not to directly study to become physicians but instead to follow a program of education to become pathologists, learning the day to day patient responsibilities of a pathologist which are quite different than that of a physician? Starting out in the direction of pathology and not a direct patient caregiver would save pathology students 4 years of time and perhaps excessive and unneeded education and 4 years of tremendous unnecessary expense. Currently, this is not the case and after 4 years of medical school comes many more years of specific training in pathology for those who have decided to make pathology as their career. My view is that the 4 years of medical school education for them is largely a waste. The training for pathology should start out in the details of pathology as needed for the career itself and the degree of doctorate would most appropriately be a PhD . In these days where the cost of medical education continues to rise both for the student and the medical school and the societal need, particularly now in the United States, for more trained physicians to attend to the increasing numbers of patients, particularly for general care, there should be changes in medical education programs to make the programs fit the goals of the students and eliminate unnecessary education.

Oh, I know a very realistic argument against what I have written. Yes, the majority of students finishing college and accepted for medical school enter medical school without a clear idea of what medical specialty they want as their career. It may be only until the 3rd and 4th year clinical clerkships that a specialty becomes a goal. Pathology may be a specialty only selected in these later medical school years or even later in education and experience. But completing college with a direction specifically to pathology requires the construction of a graduate school of pathology and then to educate undergraduate students about this career: this career of significantly contributing to the health and welfare of the living as well as contributing to the benefit of society even when dealing with the deceased. This should be an activity as priority for organizations like the American College of Pathology and other professional organizations, to work to develop such schools. Then work with university career counselors and science departments to provide students, particularly those who are planning to apply to medical school with introduction, knowledge of pathology as a career contrasting to the life and work as a physician. Experiences should be created including the "trailing" of the professionals at work. Then, rather than applying and being admitted to medical school, the students would move directly into a post-graduate school program to become pathologists, not physicians, and with a PhD after their name.

In conclusion, a philosophical and practical question is whether a pathologist could still contribute to the living and to society and science without the first 4 years of training to become a physician and an MD or DO degree. Is there something intrinsic to a pathologist's profession that demands he or she be a physician? I would like to read responses to this suggestion of mine by pathologists and non-pathology physicians and the general public, knowing the conditions and needs of the 21st century. ..Maurice.

Anonymous PhD, Can you explain a bit further what aspects within "job practice and their corresponding philosophical approach to their science" leads you to your conclusion? If a pathologist finds a "new" (previously unconsidered by the patient's physicians) cause of death and provides the rationale to the physicians to consider that disease in later patients something consistent with the goals of a PhD? ..Maurice.

Your opinion piece, though meaning no ill-will, illustrates your frankly extreme lack of knowledge of the practice of pathology.

I am a pathologist. I can tell you that my work primarily concerns the accurate diagnosis of biopsies and resections so that patients can have an idea of their prognosis and management options. Most of this involves cancer in some form or another. It does not involve autopsies, research, or running automated lab machines.

Could a PhD do this? Sure. Could a PhD do your job? Sure. But should they? No.

Why not? I think you failed to realize that pathologists are first and foremost physicians, and a physician's first duty is to his patient. Every time I look at a slide, I am examining a patient, one-on-one, just in a different way than you do, from behind the scenes. I take full responsibility for the diagnoses I render, and I will go to the ends of the earth to make sure I have the tools and knowledge to do this in the best way possible. PhDs have no such mandate, have taken no such oath, and exist to serve science on a research basis, not patients on an individual one. Furthermore, a high standard of clinical acumen is required to render diagnoses safely and accurately, and to relate what's on the slide with patient presentation. PhDs do not have this background, nor would they have this background if a special "pathology" program as you proposed existed.

The field of pathology has harmed itself by focusing on its arcane roots - autopsies, investigative pathology, pathophysiologic mechanisms for common illnesses that are no longer cutting-edge nor used in practice - and not on our primary role: diagnosis of patients. This regrettably causes our patients to forget our existence, and our colleagues(much like yourself) to wonder why we are even doctors in the first place.

I suspected that this would be a controversial topic for discussion and reading the two comments by my visitors already posted, I think my suspicion was correct.

With regard to Dr.Villiers' view, though I would agree that all physicians' duty including those who have an MD degree as a pathologist have as a first duty the patient . Even if the duty is that of diagnosis without the laying on of hands on the living patient or in the case of the deceased, the duty remains still for the historical story of the patient and also duty toward the family and, in many cases, to society. But, a point that I wanted to argue is that the majority of time spent in medical school is directed at learning to professionally and directly (eye to eye) react to issues presented by the living patient. The students learn to take a history, perform a physical examination, present diagnostic possibilities to the patient, present appropriate diagnostic tools and possible treatments to the patient and in the latter two years learn to treat. All this education does take time and necessary life patient interaction. By presenting the argument on this thread, I am just wondering whether all this direct, time consuming education is really necessary and appropriate for a student who will go into pathology. Of course, there may be many students who decide on their pathology career in the last years of medical school or even beyond. That is why I wondered whether some pre-medical course or program might prove useful to stimulate and identify students into the pathology profession and direct them into some pathology PhD schooling before unnecessarily entering into a full MD or DO education program. Anyway, I look forward to a pathologist coming here and supporting my contention. Maybe there are none. ..Maurice.

Such a program you describe would also apply to the study of radiology, since that is, like pathology, not based in patient interaction but in providing diagnoses by examining images. You haven't mentioned them in the same breath, which goes to show that pathology has failed to demonstrate its true value to medicine. I think you're still focusing on the autopsy aspect of pathology, which is frankly a minority(and a loud one at that). I think you should go down to the pathology department and spend a week seeing what it is they are doing. Maybe then you'll gain an appreciation for it as a part of medicine.

If you were to ask me if PhDs could do autopsies, I'd probably agree with you. But for making diagnoses that affect patients, the MD or DO provides a kind of guarantee that the person who is doing that job is of a high moral and ethical standard - higher than that of a PhD who would be trained to do the same. A PhD trained in patient interviewing and clinical diagnosis could do your job too, but should not due to the same thing.

As for most of medical school being useless for pathology training, you are entirely wrong. There is far more to medicine than gathering data from patients, and far more to pathology than looking at slides. And much of what is learned in medicine is based on the outdated Flexner primary care model. To extend your suggestion, perhaps we should have direct entry obstetric schools because the rest of medicine is not used by them. Same goes for pediatrics. Or maybe we should do the same with orthopedic surgery.

To single pathology as the odd man out in medicine is frankly ignorant.

I still don't see the ongoing (face to face or eye to eye) doctor-patient diagnostic, procedural and therapeutic relationship and the need to learn and practice that relationship as part of the pathologist's activity with live patients. In the case of radiologists, many are becoming interventional and they may be becoming almost equivalent to surgeons.

I can't put obstetrics, pediatrics nor orthopedic surgery in the same category considering doctor-patient relationships as pathologists. Their specialties don't remove them from the necessary education for the intimate doctor-patient relationship which we teach in medical school. It just seems to me that for working only as a pathologist, this intense education is unneeded. ..Maurice.

My comment only applies for anatomic pathology (which represents more than 80% of pathologists' duties)

1) When as an internist you perform your preop assessment, you need to know about the kind of surgery that has to be done. That's why surgery clerskhip is useful for internists. When a pathologist is covering frozens, they have to know what's being performed. When you get a whipple resection and you have to identify the margins while the patient is still on the table, trust me it helps to have a sound surgical background.

2) Like the pathologist above me mentioned, pathologists mostly deal with ruling out/ruling in/classifying cancers. Not only do they classify and stage cancers, they also look for prognostic and therapeutic informations. They need heme/onc background to be able to understand the various molecular tests they are ordering on their tissues (HER2 for breast, BRAF for melanoma etc etc).

4) Many drugs and toxic compounds can affect tissues and knowledge in pharmacology is crucial in pathology.

5) Maybe it's different at your institution, but at mine, H&P and pt-doctor relationship represented less than 20% of preclerkship and roughly 2/3 of clerkship. We had A LOT of basic sciences in year 1-2. Our medical eduction is very relevant in pathology. I can't see anyone tackling a pathology case for the first time without knowing the different possible and common diagnoses beforehand (it would be impossible... you have to know about Barett esophagus before being able to look at a slide showing you the disease).

6) Indeed, we don't examine and interview patients. We're not going to use that skill in pathology (a skill that represents 20% of preclerkship and 2/3 of clerkship to learn). However, our reasoning and methodology is pretty much the same. Our H&E (routine stain) constitute our H&P. Our immunohistochemical studies, molecular studies etc are our investigation.

7) A pediatrician or an internist will only use extremely basic anatomy/histology in his practice, and barely uses any biochem. Therefore, if I follow your logic, Preclerkship is wasted on those specialists, and maybe they could get away with a 6 months training in medical foundation 1) A pathologist is a doctor. They diagnose diseases, including every single human cancer. Diagnoses are an integral part of medicine, and pathologists make the most powerful ones. Why then should someone other than a physician take care of such an important aspect of medicine, the cornerstone of everything else/every treatment, the absolute gold standard of diagnostics? (who cares about what the notochord is when you're an internist? ...)

8) Try reviewing a medical chart before an autopsy if you're not a physician... good luck (by the way we routinely review the charts of our patients in pathology because the clinical info provided in the request is often insufficient or plain wrong).

A pathologist is a doctor. He diagnoses diseases including every single human cancer. Diagnoses are an integral part of medicine, and pathologists make the most powerful and crucial ones. Why then should someone other than a physician take care of such an important aspect of medicine, the absolute gold standard of diagnostics, the cornerstone of many many treatments, from minor surgery to major resections, to chemo and radiation therapy?

Of course, I am speaking from the viewpoint of having taught first and second year medical students for over 25 years and before that had experience with later years of medical education on the wards. If we take the statistics of Anonymous from 8:54pm today, that still is a lot of time (and money) spent by the student and med school to experience clinical exam and procedure techniques in face to face relationships with patients and not strictly related to what pathologists actually do. How about a compromise? Have a special MD pathology education in medical school but limited to, lets say, 2 years but without direct patient interaction and then moving on to graduate studies to complete the MD pathology residency. Wouldn't that be a more reasonable and logical process of pathology education? With this approach there would be no PhD program in a separate non-medical school environment and the graduates would still leave with a degree of Doctor of Medicine in Pathology. Anyone want to discuss that suggestion? ..Maurice.

I think a compromise is impossible just for path, but you could change the whole system and shorten med school for every specialty. That would make a lot of sense. Our system isn't efficient, and midlevels prove it well. The real question is: do primary care physicians really need an MD? Do anesthesiologists really need an MD? Those are 2 fields where 50-75% of their cases are handled by midlevels (PAs, NPs, CRNAs). It's not the case in pathology.

Related to our current discussion is the matter of whether hospital pathologists should be advised and motivated to leave their hospital labs and go out on the ward and visit with the patients for whom they are consulting. How often have patients had the opportunity to meet with and discuss the pathological findings directly with the pathologist? I agree that the pathologist may view the patient in the operating room but the patient would be unconscious. And I don't mean a visit with the patient which is just a "cameo appearance" where the doctor says simply "Good morning, I am your pathologist and I wanted to drop in and say hello and wish you the best." I mean a visit where all the pathology issues are described to the patient directly by the pathologist. I am just wondering whether information about the pathology and clinical consequences are adequate information for patient decision-making when simply "translated" through the words of the attending physician. If pathologists would do a little more "one on one" interaction with their patients, the patients could be much more benefited and any argument against that MD after the pathologist's name would be less supported. (This should get a discussion going here!)..Maurice.

Perhaps it is wise to let my visitors here to know a bit more from what perspective I have written this obviously controversial article. (For those who did't make their journey here from the Student Doctor Network where this thread has developed some fire, you might want to take a look there.)

I look at the education of pathologists as an instructor in my medical school's "Introduction to Clinical Medicine" (ICM) course in which first year medical students beginning in their very first days of school ate already directly relating to hospitalized patients and performing medical history taking from them. These first year students start performing physical examinations later in their year and perform complete histories and physical examinations in their 2nd year. These are all weekly 4 hour sessions. Of course, there is direct patient interaction in the 3rd and 4th year clerkships. Throughout the entire 4 years, the students are immersed in interaction with live patients, their course and their care. The system sciences along with pathology, physiology, psychiatry and pharmacology occupies their time away from ICM.

So my perspective is from a teacher of student-patient eye to eye,hand on a living patient point of view and I still am blind as to how this particular medical school education is of practical use to those students who find their career is one of pathology. Continue to educate me. ..Maurice.

Dr. Bernstein: I think you have to take everything into perspective. Your weekly 4 hour/week introduction to clinical medicine is only a tiny percentage of the medical school curriculum. True, it is probably a waste of 4 hours a week for a pathologist who won't be taking a history or doing a physical exam. But how about the rest of the 76 hours per week (or more) that medical students are spending learning other things?

Although there is direct patient interaction in third and fourth year clerkships, a huge proportion of the time is spent reading, learning about disease mechanisms, differential diagnoses, and management.

That 4 hours a week that students spend in ICM is almost insignificant when compared to everything else that is learned during the first two years. And there is nothing that solidifies knowledge more than real experience that comes with interacting with patients and learning about their diseases first hand.

Then why couldn't the pre-degree learning period for those students who want pathology as a career be set in a schooling medium of shortened duration (and less student expense) and away from the purely clinical interaction and therapy of live patients? And what is wrong with a PhD degree? I think that comparing intellectual work attaining a PhD may be more challenging than a MD and can't respect for the accomplishment and work be equal? I don't think it is the degree, as such, but the value of the bearer to the patient. ..Maurice.

The physical exam is key in performing fine needle aspirate biopsies and bone marrow biopsies, both of which I perform. I am glad to say that the patients I see have commented positively on my bedside manner, and my ability to explain either their disease or the reason for their procedure better than some primary clinicians. I am an anatomic and clinical pathologist in practice for 13 years with 10 years of medical student and pathology residency teaching/training in an academic setting. In my experience, the best pathologists I have worked with and trained, have been those that have a thorough understanding of clinical medicine, and particularly those who have been exposed to the surgical specialties, internal medicine, and GYN, sometimes as their first residency. As a first year resident in the mid 1990's I saw that those pathologists who trained in the 70's and 80's and did an internship clinical year, had a leg up in learning pathology. The pathologic slide may hold the diagnosis for a patient and be obvious, but often may be just one piece of a complicated puzzle that needs correlation with radiologic imaging and laboratory testing. If the diagnosis is not straightforward, there is a fine art to judging based on the clinical situation, how far we can go with the tissue we have what to recommend next. We are consultants for our surgeons on a regular basis in this way. This is the art of medicine we are taught in medical school. I routinely correlate liver disease biopsies with liver function tests, correlate bone lesions and fibrotic lung diseases with the radiology (I look at the CT and Xrays myself with or without a radiologist/clinician), and I communicate complicated findings to my clinicians and sometimes assist with communicating with patients. In the past I have assisted communicating autopsy findings in multidisciplinary conferences with grieving parents, and have on occasion reviewed a pathologic slide with a patient or patient's family (after the approval of the clinician). As a teacher, I am happy to do this and enjoy being involved with patients' understanding of their disease processes. Pathology requires a broad knowledge base and the ability to communicate with people verbally and in writing. The best pathologists are those that can not only render the most accurate diagnosis possible by fully understanding the clinical situation and implications, but can also communicate clearly with patients- either directly or indirectly. -AGG

AGG, thanks for a very informative commentary. Would you say that your experience in medical school, learning and experiencing medical school "life" both formal education and personal with other students who were to become internists or surgeons or other specialties has helped you in understanding their issues and problems both personal and professionally as they deal with their patients and helps you communicate with them now as physicians? In other words, if the course of education to become a pathologist was spatially separated but also the pathology student was on a different track and not interacting daily with medical students, this would lead to problems with later professional interaction and communication.

My other issue is the admitted lack of regular access and direct communication by professional pathologists with the patients from whom tissue or fluids were taken. Doesn't that diminish the need for the close patient interaction which is part of the medical students learning experience? ..Maurice.

I am currently a pathology resident (AMG). I chose pathology because to me, every interesting case that occurs in the hospital goes through the pathology department (be it SPEPs, biopsies, or apheresis). It seems to me that the pathologist has to have the same background as a "clinician" in order to help them appropriately order lab tests etc. Not only that but pathologists also perform apheresis, another procedure in which you interact with the patient. I would suggest you spend some time in your pathology department- signing out non-cancer cases, such as medical liver or GI biopsies, usually requires a MD background as the histologic findings are not black and white and some patient clinical information is necessary.

I am deeply offended by your post and while I appreciate you wanting to understand more about the field, it really seems like you need to make a field trip. I feel like pathology and radiology are very similar fields that require a clinical background to appropriately handle cases.

Anonymous from today September 29 2013:You should not feel offended since this is a bioethics discussion blog.

Discussion of a subject, if ad hominem references to specific discussants is disallowed, becomes a fair and useful method for understanding an issue by all parties participating. I have, for the purpose of discussion, selected a view which is reasonable and not grossly irrational to begin a discussion. Unfortunately, to date no visitor to this blog has appeared to support that view. But who knows?

You may ask what is the value of such a discussion about the merits of an MD or DO degree in the education of a pathologist. Think about the possibility of some college student coming to this blog who previously was thinking to become a pathologist. After reading the descriptions of the specialty and its relationship to physicians of other specialties and arguments presented here toward the medical degree, I am sure that the student would have benefited greatly from his or her visit here in terms of understanding more about the specialty.

So feel no offense. At least two sides of a discussion are necessary to stimulate insight into all aspects of a controversy and make a discussion meaningful rather than being simply sermonizing. ..Maurice.

I don't think that one can simply say it's a "discussion" and allow themselves to spill ignorant nonsense onto the unsuspecting public. Pathologists are firmly entrenched into patient care, often far more than the average internal medicine physician sitting on their Epocrates software punching in numbers. The Pathologist makes diagnoses which actually MATTER and impact patient care greatly. In order to make a valid and working diagnosis; one MUST UNDERSTAND the basics of patient care, clinical history, physical exam, and imaging.

I don't know what kind of broken medicine you practiced and with what kind of broken Pathologists you interacted with; but it is obvious that you are from an older time where people didn't understand how a TEAM works. Times have changed....the world has changed.

Since this is a discussion, i would question your abilities as a Physician if you do not understand HOW COMPLEX Pathology is as a field. Arguably more intricate, detailed, and complicated than any other specialty of medicine.

Your alibi of this being a 'discussion' is not an excuse to spill ignorance into the world.

Additionally: since Internal Medicine physicians HARDLY understand how the body actually works----let's NOT teach them anatomy or histology or cell biology. What's the use, according to your demented theory!?

Len, discussions on a bioethics listserv or, in fact, anywhere should meet the definition of discussinn which is "the action or process of talking about something, typically in order to reach a decision or to exchange ideas". One thing every discussion should NOT include are ad hominem remarks as present in your recent postings. The goal of a discussion is to talk about the topic under discussion and not to include commentary to degrade or insult persons, as a person, who may present a view that may be contrary to the view held by the writer or speaker. A discussion is about the topic under discussion and not personally about any one of the participants. If someone writing to this blog disagrees with the proposition presented by me or anyone else here, the discussant's next step is to argue and document their support for their own view and and describe the logical errors or inconsistencies of the opposing arguments but NOT to use or describe the opponent's personhood as part of the argument. Ad hominem, to use the person as part of the argument has no merit and should be absent in a discussion. ..Maurice.

Dear Maurice, your discussion is definitely controversial. But as Dr. Villiers has already mentioned that inorder to give an accurate diagnosis a patient history is as important for a pathologist, as it is to a physician (Internal medicine/ pediatrics/ obgyn, you name it). This situation more applies to rule out cancers from other diseases (eg if the patient is coming in with a thyroid mass or a nodule, or the patient has arbitrary thyroxine levels, which led to a biopsy the confirmation ofcourse comes through a pathologist only). One cannot expect a student who has not been through medical training to have the knowledge of patient care and come up with the diagnosis, without really understanding the difficulty the patient is facing. Yes! the pathologists do know and have to know what their patients are going through, they still have to empathetic and not just robots. May be that is the reason why the pathologists are sometimes referred to a doctor's doctor as they need to know the patient history while going through the specimens inorder to come at an accurate diagnosis. It's not just plain preparation of slides and providing a diagnosis, if you have noticed it anytime.

My response to Anonymous from today is that so much of the learning and experience that medical students obtain is that of developing a doctor-patient relationship with every patient they will be responsible for. They learn how to take a history from the very beginning when the student has no idea as to what is the history and to learn how to personally "lay on hands" to examine a patient and recognize the patient's comfort and discomfort with the physical examination.

Of course, those students later becoming pathologists learn and practice all of these medical school requirements but my question to this thread has been "is there evidence that there is such a relationship between the pathologist and patient where all this knowledge and practice of the doctor-patient relationship is necessary? My concept of a clinical pathologist (and obviously responses here suggest it is wrong, is that all that training is unnecessary for a clinical pathologist and certainly for one who is working all day in the coroner's office. Yes, the pathologist needs. beyond knowledge and skills of pathology in all of its diversity and structure, skills in communication with other physicians and even, when necessary, communication with patients and family members in terms of explanation of identified disease and associated clinical outcomes. But it isn't learning to take a entire medical and social history from scratch (pertinent history coming mainly from communication with primary physicians or consultants) or the chart, or the repeated "laying on of hands" of a live and anxious patient.

If I am wrong stating all this--I still think I am correct in raising this view since this IS a DISCUSSION blog. And certainly as already documented here, this topic has been and is continuously being discussed. ..Maurice.

Dear Maurice, You are right in mentioning that Pathologists are not usually the ones laying hands on patients and they do not need to. They have a lot on their plate and they trust the physicians under whom the patients are to do the needful. Wasn't a physician in the old good days responsible for taking history and performing medical examination, they were also responsible for preparing slides, in addition to doing surgery. the divide occurred as and when the patient load increased. That is why today you have pediatrics, internal medicine, surgery, family medicine, emergency medicine and all these other branches, including pathology and radiology. In the previous days you were the doctor of internal medicine, pediatrics, you were the radiologist and in some cases even the pathologist. It is very important to remember that whatever we know of the human body is through the lens of the pathologist. It is also imperative to know that pathology addresses four components of disease: etiology, pathogenesis, morphologic changes cells and their structure and consequences of those changes, which would include the clinical manifestations. So, no matter how strong you point out that clinical history and physical examination is not required curricula for a pathologist to go through think again. Because if one does not know the initial clinical manifestations then I would doubt it would be easy to tackle or even find out the later clinical manifestations.

It is like someone telling an internal medicine physician, that you do not need the pathology or anatomy course you are not using them in your specialty. Breaking news! You need those even if you are not using it directly, those subjects from your foundation. Similarly, for a pathologist they need to have an understanding of the history and physical examination aspects as all the medical students do, irrespective of you choose an internal medicine or radiology or pathology residency for that matter.

I wonder if this would be a surprise to you that the first pathologist were also practicing clinicians. If yous till insist that pathologist do not need to go through rigorous medical training as all medical students do, I hope you will find someone more equipped to dispense your ignorance.

Of course the pathologist needs to have studied how to evaluate a given history, a given physical exam and given laboratory studies. And of course a pathologist needs to have studied human anatomy and physiology and all the basic sciences taught in medical school as well as, of course, all of pathology taught and then even more. But, much of the last 2 years of medical school is spent by students attending to the daily, hourly or even minute by minute or even more frequent, the latter periods with severely and acutely ill patients. Not looking through a microscope or running a lab machine but starting and stopping IVs, writing orders and reevaluating the patient's responses to the therapy. All of this is taking up time and tuition costs as a medical student and all of this may not be really necessary if the student's aim is to be a pathologist. What is wrong to have the career as a pathologist taken out of medical school but supplying that student with all the technical knowledge and medical details for his or her pathology profession without having to day in and day out especially in years 3 and 4 to be a medical student and have all their educational patient experiences and responsibilities?

This is the point of this discussion: Shouldn't the contributions of a skilled PhD pathologist to the health and well-being of a patient or to the community as a forensic pathologist be considered equal to an MD physician or surgeon? This is what I wanted to throw open for discussion. ..Maurice.

It is an interesting argument that 'clinical training is necessary to a pathology career just as the study of human anatomy is vital to be a physician' since some medical schools now have anatomy as an 'optional' elective. The inclusion of particular subjects within any medical course is an ongoing discussion, simply because there are only so many hours in the day and the volume of knowledge is now so vast.

Also, a medical degree does not automatically confer moral judgement on a person. I can imagine some doctors being less understanding of what the patient is going through due to the ridiculous hours they sometimes work or due to their own life view or current crises, than some scientists who have focused on a particular disease and understand it and all its complexities backwards.

This was an interesting discussion to go through. I can understand why it might have been offensive to some, but at its heart I think the proposal has great merit. I do not believe the PhD is appropriate since to me that is a mostly academic degree, not a professional one (although PhDs in engineering are also professional degrees) - but PathD has a nice ring to it (perhaps with an optional PhD component if an adequate thesis is submitted). I think it would be comparable to a professional degree in pharmacy, since pharmacists also require much of the same background knowledge as MDs and also work in a team with other health care professionals, as has been previously mentioned.

I myself am a last year college student interested in diagnostic specialties such as pathology and radiology, and I admit the proposal appeals to me because, in part, I feel ill at ease with what the admissions committees seem to be looking for. I want to directly help patients and collaborate with other doctors, and I would be very open to speaking with patients if they wanted to see me, but I am also a fairly introverted and socially awkward person who wouldn't be able to inspire confidence in patients if I were to meet them as their primary care physician. Medical students, at least in my area, are increasingly being selected for personality traits. We actually had a situation a few years back where there were no MDs interested in a clinical genetics (diagnostic laboratory) training program and the position went to a PhD even though they gave preference to MDs. That's what happens when you select for people who are naturals at direct human interaction.

It might not be appropriate to single out pathology anymore than the other diagnostic specialties, but it would certainly make sense to reform medical school to be more specialized after the first 2 or so years of shared basic courses.

I am a pathologist.I will admit the pathology in the past has some image issues but this is being progressively addressed and the practice of pathologists depend on the institution.Our department has fine needle aspiration biopsy clinic and so we do history taking and clinical examination, we do adequacy for image guided biopsies in radiology, we do frozen sections, we talk to patients and clinicians for special tests that may be required for certain specimen, we talk to relative of patients prior to autopsy and we talk to patients if they have queries before their blood works.The surprising thing is sn internist open this topic and spilled a whole lot of 'information'on how he understands pathology.Whatever your age, you clearly belong to those old doctors who think that pathology is all about autopsy and they reside in the morgue.This article is not thought provoking,it is OFFENSIVE.

At least, it seems, pathologists "apeak out what they think" and, you know, ventilation is not a bad therapeutic tool. This discussion also gives my lay visitors a chance to learn from pathologists what the career of medical pathology is all about and what the patient should expect from their pathologist. So all in all, I am not upset or have second thoughts of whether I should have started this thread. In fact, I definitely thank all the professionals who have so far participated here. So, thank you. ..Maurice.

Dr. Bernstein, In India MD in Pathology is a post-graduate degree, just as an MD in any other area (Internal Medicine, Pediatrics, Dermatology, etc.). An MBBS degree which involves being a certified physician is the gateway to MD in Pathology. This means that with an MD in Pathology, one can be a faculty member in a Medical School, work in the lab of a premier hospital, or see patients as a general physician in a private clinic or hospital by virtue of having an MBBS degree. So in India, for an MD in Pathology, in terms of opportunities, I feel, sky is the limit. From what I understand (I am a PhD in Mechanical Engineering), Pathologists may have to even perform biopsies; do you think that a PhD degree-holder can perform such procedures?

I think your viewpoint is primarily due to a limitation in American medical system. Hope you will revise your opinion based on the above feedback and think more holistically.

Perhaps, with their MD degree, even pathologists in the United States, in their "spare time" could help out our physician shortage here and taken on a few patients as a general practice physician. Oh.. will that get me into trouble with the pathologists coming to this thread! ..Maurice.

I am sorry that the pathologists you have interacted with over your career have led you to ask such a laughable, ill-informed question. Medical diagnosis is more and more a process of interdisciplinary triangulation. Nosologic entities multiply over time, just as the quantity of biopsy tissue has been shrinking. To obtain a definitive, clinically relevant diagnosis, the pathologist has to consider clinical and radiological findings. Trying to diagnose from only tissue will lead to disaster time after time. True, I guess you could train a non-physician to do these things, but when you do, you may as well hand them the MD or DO diploma, because that's what they would de facto be.

I have no argument with the understanding that a pathologist making a patient diagnosis requires more than observing some tissue under a microscope. It requires, as Ed stated, clinical and radiological findings. My point which I have offered is that the clinical findings (history and physical) are based on the patient's story and physical findings obtained by the patient's physicians and not directly obtained from the patient by the pathologist. How often does the pathologist go into the patient's room, sit down and try to obtain elements of the history which would be pertinent to a final diagnosis and which was not included in the clinical information provided by the patient's physician on the case? How often would the pathologist stand over the patient to check for a physical finding which would be pertinent to the formation of diagnosis but not provided by the patient's physician? And how often is it that the pathologist sits down with the patient to explain the findings found by the pathologist and answer questions from the patient about the details of the pathologist's diagnosis. It is all this intimate doctor-patient and not simply doctor-doctor relationship that maybe the hallmark of a physician who carries a doctor of medicine degree.

Now again I want to emphasize that what I have presented above is the example of what a moderator can present as another viewpoint which is then open for discussion and debate, particularly if that viewpoint had not been offered by the participants. Are there not at least two sides to most issues and the question of what makes a participant in medical diagnosis and treatment a "physician" open for discussion?

How often does a pathologist check the history? Pretty much every time. How often do we see and sit down with patients rarely or daily depending on your subspecialty. Cytopathologist and hematopathologist see patients regularly in clinic if performing biopsies. Other pathologist have little to no interaction with patients directly. However, 92% of all patient information is generated from the lab and hence the pathologist. In molecular Pathology there would be very few capable physicians outside of Pathology than can even begin to understand the current data generated in a clinical setting. What you are saying is equivalent to me saying that IM are not legitimate doctors because they don’t use surgery on a regular basis or may even incorrectly assume that they are not utilizing the pathologist with daily labs. Furthermore, most pathologist are in direct interaction with clinical fellows in surgical sub specialties, gen Surg, IM, heme/onc etc. Hell, I’ve even had psych stop by for a consult. What you have said is so laughable and absurd it’s infuriating.

Looking back over the years this blog thread subject has be read and written to, I feel strongly that I did the right thing in bringing up this professional detailing. It certainly provided those deciding to enter the profession of pathology a modern description of the profession itself and its relationship to its patients. Isn't that what a discussion is all about..in part,to educate those interested to learn about the subject. I think the variety of postings here has certainly done that. ..Maurice.

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